TY - JOUR
T1 - Serum Potassium and Mortality Risk in Hemodialysis Patients
T2 - A Cohort Study
AU - de Rooij, Esther N. M.
AU - Dekker, Friedo W.
AU - le Cessie, Saskia
AU - Hoorn, Ewout J.
AU - de Fijter, Johan W.
AU - Hoogeveen, Ellen K.
AU - Netherlands Cooperative Study on the Adequacy of Dialysis-2 (NECOSAD) Study Group
AU - Bijlsma, J. A.
AU - Boekhout, M.
AU - Boer, W. H.
AU - van der Boog, P. J. M.
AU - Büller, H. R.
AU - van Buren, M.
AU - Charro, F. Th. de
AU - Doorenbos, C. J.
AU - van den Dorpel, M. A.
AU - van Es, A.
AU - Fagel, W. J.
AU - Feith, G. W.
AU - de Fijter, C. W. H.
AU - Frenken, L. A. M.
AU - Grave, W.
AU - van Geelen, J. A. C. A.
AU - Gerlag, P. G. G.
AU - Gorgels, J. P. M. C.
AU - Huisman, R. M.
AU - Jager, K. J.
AU - Jie, K.
AU - Koning-Mulder, W. A. H.
AU - Koolen, M. I.
AU - Hovinga, T. K. Kremer
AU - Lavrijssen, A. T. J.
AU - Luik, A. J.
AU - van der Meulen, J.
AU - Parlevliet, K. J.
AU - Raasveld, M. H. M.
AU - van der Sande, F. M.
AU - Schonck, M. J. M.
AU - Schuurmans, M. M. J.
AU - Siegert, C. E. H.
AU - Stegeman, C. A.
AU - Stevens, P.
AU - Thijssen, J. G. P.
AU - Valentijn, R. M.
AU - Vastenburg, G. H.
AU - Verburgh, C. A.
AU - Vincent, H. H.
AU - Vos, P. F.
N1 - Funding Information: The NECOSAD was supported by grants from the Dutch Kidney Foundation and the Dutch National Health Insurance Board . Funding Information: A.J. Apperloo, J.A. Bijlsma, M. Boekhout, W.H. Boer, P.J.M. van der Boog, H.R. B?ller, M. van Buren, F.Th. de Charro, C.J. Doorenbos, M.A. van den Dorpel, A. van Es, W.J. Fagel, G.W. Feith, C.W.H. de Fijter, L.A.M. Frenken, W. Grave, J.A.C.A. van Geelen, P.G.G. Gerlag, J.P.M.C. Gorgels, R.M. Huisman, K.J. Jager, K. Jie, W.A.H. Koning-Mulder, M.I. Koolen, T.K. Kremer Hovinga, A.T.J. Lavrijssen, A.J. Luik, J. van der Meulen, K.J. Parlevliet, M.H.M. Raasveld, F.M. van der Sande, M.J.M. Schonck, M.M.J. Schuurmans, C.E.H. Siegert, C.A. Stegeman, P. Stevens, J.G.P. Thijssen, R.M. Valentijn, G.H. Vastenburg, C.A. Verburgh, H.H. Vincent, and P.F. Vos. Esther N.M. de Rooij, MD, Friedo W. Dekker, PhD, Saskia Le Cessie, PhD, Ewout J. Hoorn, MD, PhD, Johan W. de Fijter, MD, PhD, and Ellen K. Hoogeveen, MD, PhD, Research idea and study design: ENMdR, EKH, FWD, JWdF; data acquisition: FWD; data analysis/interpretation: ENMdR, EKH, FWD, JWdF; statistical analysis: ENMdR, EKH, SLC, FWD; supervision or mentorship: EKH, FWD, JWdF, SLC, EJH. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. The NECOSAD was supported by grants from the Dutch Kidney Foundation and the Dutch National Health Insurance Board. The authors declare that they have no relevant financial interests. The authors thank the investigators and study nurses of the participating dialysis centers and the data managers of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) study for collection and management of data. The authors thank the nursing staff of the participating dialysis centers and the staff of the NECOSAD trial office for their invaluable assistance in the collection and management of data for this study. Received June 9, 2021. Evaluated by 2 external peer reviewers, with direct editorial input by a Statistical Editor and the Editor-in-Chief. Accepted in revised form August 18, 2021. Publisher Copyright: © 2021 The Authors
PY - 2022/1/1
Y1 - 2022/1/1
N2 - Rationale & Objective: Both hypo- and hyperkalemia can cause fatal cardiac arrhythmias. Although predialysis serum potassium level is a known modifiable risk factor for death in patients receiving hemodialysis, especially for hypokalemia, this risk may be underestimated. Therefore, we investigated the relationship between predialysis serum potassium level and death in incident hemodialysis patients and whether there is an optimum level. Study Design: Prospective multicenter cohort study. Setting & Participants: 1,117 incident hemodialysis patients (aged >18 years) from the Netherlands Cooperative Study on the Adequacy of Dialysis-2 study were included and followed from their first hemodialysis treatment until death, transplantation, switch to peritoneal dialysis, or a maximum of 10 years. Exposure: Predialysis serum potassium levels were obtained every 6 months and divided into 6 categories: ≤4.0 mmol/L, >4.0 mmol/L to ≤4.5 mmol/L, >4.5 mmol/L to ≤5.0 mmol/L, >5.0 mmol/L to ≤5.5 mmol/L (reference), >5.5 mmol/L to ≤6.0 mmol/L, and >6.0 mmol/L. Outcomes: 6-month all-cause mortality. Analytical Approach: Cox proportional hazards and restricted cubic spline analyses with time-dependent predialysis serum potassium levels were used to calculate the adjusted HRs for death. Results: At baseline, the mean age of the patients was 63 years (standard deviation, 14 years), 58% were men, 26% smoked, 24% had diabetes, 32% had cardiovascular disease, the mean serum potassium level was 5.0 mmol/L (standard deviation, 0.8 mmol/L), 7% had a low subjective global assessment score, and the median residual kidney function was 3.5 mL/min/1.73 m2 (IQR, 1.4-4.8 mL/min/1.73 m2). During the 10-year follow-up, 555 (50%) deaths were observed. Multivariable adjusted HRs for death according to the 6 potassium categories were as follows: 1.42 (95% CI, 1.01-1.99), 1.09 (95% CI, 0.82-1.45), 1.21 (95% CI, 0.94-1.56), 1 (reference), 0.95 (95% CI, 0.71-1.28), and 1.32 (95% CI, 0.97-1.81). Limitations: Shorter intervals between potassium measurements would have allowed for more precise mortality risk estimations. Conclusions: We found a U-shaped relationship between serum potassium level and death in incident hemodialysis patients. A low predialysis serum potassium level was associated with a 1.4-fold stronger risk of death than the optimal level of approximately 5.1 mmol/L. These results may imply the cautious use of potassium-lowering therapy and a potassium-restricted diet in patients receiving hemodialysis.
AB - Rationale & Objective: Both hypo- and hyperkalemia can cause fatal cardiac arrhythmias. Although predialysis serum potassium level is a known modifiable risk factor for death in patients receiving hemodialysis, especially for hypokalemia, this risk may be underestimated. Therefore, we investigated the relationship between predialysis serum potassium level and death in incident hemodialysis patients and whether there is an optimum level. Study Design: Prospective multicenter cohort study. Setting & Participants: 1,117 incident hemodialysis patients (aged >18 years) from the Netherlands Cooperative Study on the Adequacy of Dialysis-2 study were included and followed from their first hemodialysis treatment until death, transplantation, switch to peritoneal dialysis, or a maximum of 10 years. Exposure: Predialysis serum potassium levels were obtained every 6 months and divided into 6 categories: ≤4.0 mmol/L, >4.0 mmol/L to ≤4.5 mmol/L, >4.5 mmol/L to ≤5.0 mmol/L, >5.0 mmol/L to ≤5.5 mmol/L (reference), >5.5 mmol/L to ≤6.0 mmol/L, and >6.0 mmol/L. Outcomes: 6-month all-cause mortality. Analytical Approach: Cox proportional hazards and restricted cubic spline analyses with time-dependent predialysis serum potassium levels were used to calculate the adjusted HRs for death. Results: At baseline, the mean age of the patients was 63 years (standard deviation, 14 years), 58% were men, 26% smoked, 24% had diabetes, 32% had cardiovascular disease, the mean serum potassium level was 5.0 mmol/L (standard deviation, 0.8 mmol/L), 7% had a low subjective global assessment score, and the median residual kidney function was 3.5 mL/min/1.73 m2 (IQR, 1.4-4.8 mL/min/1.73 m2). During the 10-year follow-up, 555 (50%) deaths were observed. Multivariable adjusted HRs for death according to the 6 potassium categories were as follows: 1.42 (95% CI, 1.01-1.99), 1.09 (95% CI, 0.82-1.45), 1.21 (95% CI, 0.94-1.56), 1 (reference), 0.95 (95% CI, 0.71-1.28), and 1.32 (95% CI, 0.97-1.81). Limitations: Shorter intervals between potassium measurements would have allowed for more precise mortality risk estimations. Conclusions: We found a U-shaped relationship between serum potassium level and death in incident hemodialysis patients. A low predialysis serum potassium level was associated with a 1.4-fold stronger risk of death than the optimal level of approximately 5.1 mmol/L. These results may imply the cautious use of potassium-lowering therapy and a potassium-restricted diet in patients receiving hemodialysis.
KW - hemodialysis, hyperkalemia, hypokalemia, mortality, potassium
UR - http://www.scopus.com/inward/record.url?scp=85122068588&partnerID=8YFLogxK
U2 - https://doi.org/10.1016/j.xkme.2021.08.013
DO - https://doi.org/10.1016/j.xkme.2021.08.013
M3 - Article
C2 - 35072043
SN - 2590-0595
VL - 4
JO - Kidney medicine
JF - Kidney medicine
IS - 1
M1 - 100379
ER -